Community health workers (CHWs) have gained increased visibility in the United States. We discuss how to strengthen the roles of CHWs to enable them to become collaborative leaders in dramatically changing health care from “sickness care” systems to systems that provide comprehensive care for individuals and families and supports community and tribal wellness. We recommend drawing on the full spectrum of CHWs’ roles so that they can make optimal contributions to health systems and the building of community capacity for health and wellness. We also urge that CHWs be integrated into ”community health teams” as part of “medical homes” and that evaluation frameworks be improved to better measure community wellness and systems change.

The objectives of this study were: 1) to evaluate the acceptance, effectiveness, and sustainability of a promotora (community health worker) pilot program to improve hypertension control among medically underserved Mexican Americans of the El Paso, Texas area, and 2) to demonstrate improvements in clinical measures of blood pressure, BMI and waist circumference, self-reported behaviors and changes in attitudes and beliefs about blood pressure among Mexican American hypertensives. Participants were eligible if they had been diagnosed with hypertension and if they were willing to be randomized as either participants in the intervention or as controls. A total of 58 participants enrolled in the intervention group and 40 participants served as controls. This was a 9-week promotora intervention. Health behavior constructs and clinical data were measured pre-post intervention. Perceived benefits, and two heart-healthy behaviors (salt and sodium, and cholesterol and fat) were shown to be statistically significantly different between the intervention and control groups.

While limited access to care is associated with adverse health conditions, little research has investigated the association between barriers to care and having multiple health conditions (comorbidities). We compared the financial, structural, and cognitive barriers to care between Mexican-American border residents with and without comorbidities. We conducted a stratified, two-stage, randomized, cross-sectional health survey in 2009–2010 among 1,002 Mexican-American households. Measures included demographic characteristics; financial, structural, and cognitive barriers to health care; and prevalence of health conditions. Comorbidities, most frequently cardiovascular and metabolic conditions, were reported by 37.7% of participants. Controlling for demographics, income, and health insurance, six financial barriers, including direct measures of inability to pay for medical costs, were associated with having comorbidities (odds ratios [ORs] ranged from 1.7 to 4.1, p<0.05). The structural barrier of transportation (OR=3.65, 95% confidence interval [CI] 1.91, 6.97, p<0.001) was also associated with higher odds of comorbidities, as were cognitive barriers of difficulty understanding medical information (OR=1.71, 95% CI 1.10, 2.66, p=0.017), being confused about arrangements (OR=1.82, 95% CI 1.04, 3.21, p=0.037), and not being treated with respect in medical settings (OR=1.63, 95% CI 1.05, 2.53, p=0.028). When restricting analyses to participants with at least one health condition (comparing one condition vs. having ≥2 comorbid conditions), associations were maintained for financial and transportation barriers but not for cognitive barriers. A substantial proportion of adults reported comorbidities Given the greater burden of barriers to medical care among people with comorbidities, interventions addressing these barriers present an important avenue for research and practice among Mexican-American border residents.

To address cardiovascular disease risk factors among Hispanics, a community model of prevention requires a comprehensive approach to community engagement. The objectives of our intervention were to reduce cardiovascular disease risk factors in Hispanics living in 2 low-income areas of El Paso, Texas, and to engage the community in a physical activity and nutrition intervention. Drawing on lessons learned in phase 1 (years 2005-2008) of the HEART Project, we used an iterative, community-based process to develop an intervention based on an ecological framework. New community partners were introduced and community health workers delivered several elements of the intervention, including the curriculum entitled "Mi Corazón, Mi Comunidad" ("MiCMiC" [My Heart, My Community]). We received feedback from the project's Community Health Academy and Leadership Council throughout the development process and established a policy agenda that promotes integration of community health workers into the local and state workforce. Collaboration with 2 new community partners, the YWCA and the Department of Parks and Recreation, were instrumental in the process of community-based participatory research. We enrolled 113 participants in the first cohort; 78% were female, and the mean age was 41 years. More than 50% reported having no health insurance coverage. Seventy-two (60%) participants attended 1 or more promotora-led Su Corazón, Su Vida sessions, and 74 (62%) participants attended 1 or more of the 15 exercise classes. HEART phase 2 includes a multilevel ecological model to address cardiovascular disease risk among Hispanics. Future similarly targeted initiatives can benefit from an ecological approach that also embraces the promotora model.